Provider Demographics
NPI:1154112555
Name:GOULBOURNE, TANIKA A
Entity type:Individual
Prefix:
First Name:TANIKA
Middle Name:A
Last Name:GOULBOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21608 VIOLET PERIWINKLE DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34637-4516
Mailing Address - Country:US
Mailing Address - Phone:215-221-2616
Mailing Address - Fax:
Practice Address - Street 1:2660 CYPRESS RIDGE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6324
Practice Address - Country:US
Practice Address - Phone:813-994-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical